21-Hydroxylase–deficient nonclassic adrenal hyperplasia is a progressive disorder: A multicenter study
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21-Hydroxylase–deficient nonclassic adrenal hyperplasia is a progressive disorder: A multicenter study Carlos Moran, MD, MSc,a, b Ricardo Azziz, MD, MPH,a, c Enrico Carmina, MD,d Didier Dewailly, MD,e Franca Fruzzetti, MD,f Lourdes Ibañez, MD,g Eric S. Knochenhauer, MD,a Jose A.M. Marcondes, MD,h Berenice B. Mendonca, MD,h Duarte Pignatelli, MD,i Michel Pugeat, MD,j Vincent Rohmer, MD,k Phyllis W. Speiser, MD,l and Selma F. Witchel, MDm Birmingham, Alabama, Pittsburgh, Pennsylvania, Manhasset, New York, Mexico City, Mexico, Palermo and Pisa, Italy, Lille, Lyon, and Angers, France, Barcelona, Spain, São Paulo, Brazil, and Porto, Portugal OBJECTIVE: Our aim was to determine whether the clinical features of 21-hydroxylase–deficient nonclassic adrenal hyperplasia are correlated with either age at symptom onset or age at presentation, or both, and with the degree of adrenocortical abnormality. STUDY DESIGN: In a multicenter cohort design 220 women with nonclassic adrenal hyperplasia, with a basal or adrenocorticotropic hormone–stimulated 17-hydroxyprogesterone level >30.3 nmol/L, were studied, either prospectively (n = 39) or retrospectively (n = 181). Patients were stratified by age of presentation into 5 groups: (1) 50 years old were excluded from the analysis because of age. RESULTS: Ninety-two percent of patients 6.1 nmol/L (>2 ng/mL) can serve as a useful screening value for nonclassic adrenal hyperplasia.12 As with other hyperandrogenic disorders, it is probable that nonclassic adrenal hyperplasia is a progressive disorder, with symptoms becoming worse with age. It is also possible that patients with the greatest degree of adrenocortical dysfunction, reflected in greater levels of either basal or stimulated 17-hydroxyprogesterone, or both, are also those most affected and with symptoms at a younger age. Unfortunately, our knowledge regarding the clinical features of the disorder, as well as the relationship of these features to age and to the degree of adrenocortical abnormality, has been limited because of the small number of patients studied even in the largest of published series.4, 6, 8 We now have hypothesized that nonclassic adrenal hyperplasia is clinically progressive and that the severity of symptoms increases with age and with the degree of adrenocortical dysfunction. To test this hypothesis and obtain sufficient numbers of subjects, we undertook the following multicenter study, collecting clinical and hormonal data on 220 women with nonclassic adrenal hyperplasia that provided the largest published cohort with this condition. Material and methods Subjects. Two hundred twenty women with 21-hydroxylase–deficient nonclassic adrenal hyperplasia were included from 11 tertiary referral centers. Clinical data were collected in a standardized fashion, either prospectively (since May 1995) at first-time diagnosis (n = 39) or by retrospective review of the clinical file (n = 181). All data were then maintained in a computerized database (Alpha-Four, version 2; Alpha Software Corporation, Burlington, Mass). Subjects were studied according to the respective guidelines for the study of human subjects of each participating center. Weight and height were used to calculate the body mass index (BMI), and we used the classifications of overweight and obesity proposed by the World Health Organization Expert Committee13 and expanded by Sei-
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Moran et al 1469
dell and Flegal.14 Under this classification, underweight is a BMI 40 kg/m2. Note that under this classification overweight is defined as a BMI >25.0 kg/m2 but obesity is diagnosed as a BMI >30.0 kg/m2. For comparison, we used the prevalence of obesity in the general populations from the specific countries or regions included in this study.13, 14 Patients were classified as white non-Jewish, white Jewish, Asian, black, Hispanic nonblack, and other. All cases of nonclassic adrenal hyperplasia were diagnosed by a basal level of 17-hydroxyprogesterone or a level stimulated by adrenocorticotropic hormone (ACTH) to >30.3 nmol/L (10 ng/mL), as previously described.5 Although there were minor variations among centers in the ACTH stimulation protocol, such as ACTH dose (eg, 0.25 mg or 1.0 mg) or poststimulation sampling time (eg, 30 or 60 minutes after ACTH administration), we demonstrated previously that there are no significant differences in stimulated 17-hydroxyprogesterone values obtained 30 to 90 minutes after the intravenous administration of ACTH(1-24) doses of 0.1 mg to 1.0 mg, at least in healthy individuals.15 In general, ACTH stimulation testing was performed in the morning (8 to 10:30 AM). In adolescent and adult women this test was performed in the follicular phase (days 3-8) of the menstrual cycle. Symptoms including premature pubarche, primary amenorrhea, oligomenorrhea, hirsutism, and infertility were obtained by history (ie, recall). In addition, the examining physician documented in all patients the presence of hirsutism, acne, alopecia, and clitoromegaly. The pubic hair was evaluated in children to exclude premature pubarche. In most patients the degree of hirsutism was also assessed with a modified Ferriman-Gallwey scoring method.16 Hirsutism was considered to be present with a score ≥8. In some patients, CYP21 genotyping was undertaken; however, these data are in progress and are not included in this report. Hormonal assays. The levels of 17-hydroxyprogesterone were measured by each individual participating center. The University of Alabama at Birmingham used a commercial solid-phase radioimmunoassay (RIA) (Coata-Count system; Diagnostic Products Corporation, Los Angeles, Calif), as previously reported5; the University of Palermo used a direct RIA (Diagnostic Products); the Centre Hospitalier et Universitaire of Lille used a direct RIA with a commercial kit (Beckman, Paris, France); the University of Pisa used a direct RIA with available kits (Immunochem Coated Tube; ICN Biomedicals, Inc, Costa Mesa, Calif); the Hospital Sant Joan de Deu used a direct RIA with commercial kits (Pantex Corporation, Santa Monica, Calif); the Hospital das Clinicas used an
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December 2000 Am J Obstet Gynecol
Table I. Distribution by age in 218 patients* with nonclassic adrenal hyperplasia in each of 11 centers Adults Center
Children (50 years old.
in-house direct RIA, as previously described17; the Faculty of Medicine of Porto used available kits (CIS BIO International, Gif sur Yvette, France); the Hospices Civils de Lyon used serum extraction and Celite column chromatography, with an in-house RIA, as previously reported18; the Centre Hospitalier Universitaire D’Angers used a competitive inhibition reaction, after extraction with diethyl ether and RIA with a commercially available kit (BioMerieux, Marcy-L’Etoile, France); the North Shore University Hospital used a direct RIA performed by a contract laboratory (Endocrine Science Lab, Calabasas Hills, Calif); and the Children’s Hospital of Pittsburgh used a double-antibody RIA kit (ICN Biomedicals). For the purpose of standardizing and comparing the results from each center, 10 control serum samples with varying levels of 17-hydroxyprogesterone were prepared at The University of Alabama at Birmingham, and aliquots from each of these samples were sent in masked fashion to all participating centers. The results from all centers correlated well with the results obtained at Birmingham, with correlation coefficients ranging from 0.8670 to 0.9978 (P < .001). Data analysis. Because of the nonparametric distribution, data were expressed as median and range and were compared among groups by the Kruskal-Wallis analysis of variance and the Mann-Whitney U test. The χ2 test was used to compare the proportion of positive cases for clinical features (eg, proportion hirsute, obese) among each of the age groups. The Pearson correlation coefficient was used to evaluate the relation between clinical variables. A value of P < .05 was considered statistically significant. Results The median age at presentation was 22.4 years (range, 3.8-48.0 years). The patients were stratified by age at presentation into 5 groups: group 1, age